CNS - HN - Syncope Flashcards
Differentials of Syncope
- Prolonged QT syndrome
- Aortic Stenosis
- Vasovagal
- Postural orthostatic hypotension - polypharmacy
- Postural orthostatic hypotension
- Postural orthostatic hypotension with Stroke
- Seizure due to binge drinking
- Diabetic Neuropathy
- Hypoglycemia
- TIA
- Seizure and subdural hematoma
- Seizure - idiopathic epilepsy
- Comatose
1. CNS - SAH TIA/STROKE (case) Epilepsy Migraine Meningitis Seizure
2. CVS- HOCM Arrythmias WPW Aortic Stenosis (case) Prolonged QT (case)
- Vasovagal - case
Long standing
4.Reflex-micturition, defecation, cough syncope
- Orthostatic Hypotension - case
polypharmacy
6. Metabolic Hypoglycemia - case Electrolyte imbalance (decreased K, Mg, Ca)
7. Medications Drug-induced: side effect of antipsychotic (most common cause) Abnormal Prolonged QT Syndrome Drugs • Amiodarone • Procainamide • Quinidine • Tricyclic antidepressants/Antipsychotic • Sotalol • Dizopyramide
- Trauma
- Malignancy
- Psychogenic
Differentials of Syncope
CNS
1. CNS - SAH TIA/STROKE (case) Epilepsy Migraine Meningitis Seizure
Differentials of Syncope
CVS
2. CVS- HOCM Arrythmias WPW Aortic Stenosis (case) Prolonged QT (case)
Key history - SYNCOPE / FALL
A careful history is required including an interview with family members and any witnesses to the fall.
Investigate the onset, environment and circumstances of the fall.
Consider seizure and loss of consciousness, and situational factors such as rushing to bathroom, climbing stairs or ladder. Incl. accounts of any witnesses to the fall.
Questions should incl. any premonitory or associated symptoms e.g. vertigo, lightheadedness, palpitations, chest pain dyspnoea, visual disturbance, possible unusual or disturbed behaviour.
Gather past and recent medical history incl. diabetes, hypertension, cerebrovascular disease; as well as a drug history, esp. alcohol or illicit drugs, prescription agents esp. sedatives antidepressants, hypotensives, hypoglycaemics, antipsychotics, diuretics, NSAIDs. Check thyroid status.
Key Physical examination - SYNCOPE / FALL
Key examination
•General features: appearance of patient incl. central cyanosis, hydration status, vital signs incl. pulse, BP (supine and standing) and temperature
•Look for and exclude obvious extrinsic causes of falls
•Comprehensive CVS examination
•Examine ears, eyes, oral cavity, head and neck, spine, extremities esp. feet
•Neurological examination including muscle features, sensation, coordination, balance and gait
•Mini mental state examination
Key Investigation - SYNCOPE / FALL
First line: •urinalysis •blood sugar •pulse oximetry •FBE & ESR •U&E •ECG (or 24 hour monitor).
Consider others according to history and findings: •LFTs (γGT) •TFT •echocardiography •spinal X rays •CT or MRI if indicated •Doppler studies
Diagnostic Tips
Consider rules of 7 in elderly patient:
- check mental status
- eyes
- ears
- mouth (?dentition, xerostomia)
- bladder and bowels,
- locomotion including feet
- medication.
Ideally, visit the home to assess patient’s environment and home support, incl. examination of the medicine cabinet.
Prolonged QT - Management
Investigations
- FBE, UE, BSL, betaHCG, TFT, LFT, Chest XRay, ECG.
Treatment:
- Admit
- Refer to Cardiologist/ Registrar
- Beta blocker if fails put on pacemaker
- I will also arrange a family screening for this condition (only say this if congenital)
Aortic Stenosis - Management
Investigations:
- FBE, UEC, ESR/CRP, LFT, RFT, TFT.
- ECG, and chest x-ray,
echocardiogram.
Treatment
- Admit to hospital
- Seen by specialist
- LSM - SNAP
- Avoid strenuous activity
- Surgery - Valve replacement
Vasovagal - Management
Investigations
- FBE, UCE, LFT, TFT, BSL,
- ECG
- Admit for observation
- Seen by registrar
- Do’s & Don’ts
- Don’t skip breakfast esp prior to activity/ avoid prolonged standing
- Hydration
- get up from sitting/lying slowly
POH - Management
Investigation
- FBE, ESR,CRP, LFT, UCE, TFT, BSL, lipid, HbA1C,
- ECG, echo
- Admit for observation
- Seen by specialist
- Once discharged, refer back to DM physician/cardio for review of meds
- Advise
DM control
IOF
Get up slowly
POH Stroke - Management
Investigations
- FBE, BSL, UCE, ESR CRP, - LFT, TFT,
- Urinalysis
- ECG, CT scan
- Refer to fall clinic
- MDT approach
- Monitor VS regularly
- Refer to Ophtha and ENT
- Refer to physiotherapist
- Refer to OT
- Refer to Social worker
- they might change medication dose accordingly
Seizure d/t Binge Drinking - Diagnosis
Condition - Binge drinking - imbalance of salt in body - dehydration - decrease sugar in body
Common
Cause
Clinical feature
Complication
no management
*Ddx
Diabetic Neuropathy - Diagnosis
Condition -
DIabetic Neuropathy
high sugar» sensory loss
Common
Cause
Clinical feature
Complication
no management
*Ddx - vision problem, arthritis, mini stroke
Hypoglycemia - Diagnosis
Condition -
Hypoglycemia
BSL <4mmol
Common
Cause - MEDIKA Meds Exercise Diet Infection Kidney problems Alcohol
Clinical feature
Mild
- hungry, sweaty, palpitation, shakes
Severe
- Loss of concentration, confusion, fits»_space; LOC
Complication
- if left untreated coma»_space; life threatening
